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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881153
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:29:28 PM

Document Has Been Signed on 06/02/2023 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WESTWARD RESIDENTIAL CAREFACILITY NUMBER:
331881153
ADMINISTRATOR:YBANEZ, ROSYFACILITY TYPE:
735
ADDRESS:156 FOX TROTTER PLACETELEPHONE:
(951) 665-3767
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 4DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:RosyY banezTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich and Stephanie Martinez conducted an unannounced annual visit. LPA met with the Administrator Rosy Ybanez at the front door and was granted entry. Administrator Rosy Ybanez was accompanied by Sandra Tortoledo another staff member. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. Facility is approved for four (4) clients, 3 ambulatory clients and 1 non-ambulatory client.

Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; facility temperature read at 73 degrees; residents' main restroom water temperature read at 111.7 degrees; there were no bodies of water on premises; there was sufficient lighting and mattress pads in all of the residents.All fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds.


Food Services: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.
Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. Licensee has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Last fire drill was 05/05/23.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WESTWARD RESIDENTIAL CARE
FACILITY NUMBER: 331881153
VISIT DATE: 06/02/2023
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Items reviewed/discussed: Staff present had vitamins left in a cabinet in the kitchen and the vitamins were accessible to the clients. Staff did not report acute shoulder pain of Client Two (C2) on 03/18/23 which led to the client's arm being put in a sling at the Emergency room. No incident report submitted. C2 utilizes a belt that keeps them in their wheelchair for safety. C2 has a doctor's note permitting the use of the restrictive device. C2 is non-verbal. However, the facility has not filed for an exception to utilize the device. Staff did not document that Client One (C1) received their PM medication (Benztropine Mes 1mg and Rexult 0.5mg) on 06/01/23 in the medication administration record (MAR). However, according to the Administrator, C1 was administered the medication.
Summary: Based on today's visit, no citations were issued. An exit interview was conducted with Administrator Rosy Ybanez and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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